Brookline 617-860-6430 Drydock 617-608-3695 Acton 617-860-6426

Back Index Form

Patient's Name(Required)
MM slash DD slash YYYY
This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.
Pain Intensity
Personal Care
Social Life
Changing degree of pain
Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100
MM slash DD slash YYYY
0 = no pain and 10 = worst pain
0 = no pain and 10 = worst pain
How often do you experience your symptoms?(Required)
How much have your symptoms interfered with your usual daily activities?(Required)
(including both work outside the home and housework)
How is your condition changing, since care began at this facility?(Required)
In general, would you say your overall health right now is...(Required)

Singer's Name(Required)

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